The Doctor’s Out

How Over-the-Counter Birth Control Could Screw You

The nation’s top OB/GYNs have come out for allowing access to the pill without a prescription. Sounds good for the consumer, right? Not so fast, writes Dr. Kent Sepkowitz—you’d be paying a lot more.

Overpopulation is the single most important public health problem in the world. It promotes global warming, underlies ongoing shortages of food and medication, and facilitates spread of infectious diseases—to name just a few major issues. Fortunately, though, overpopulation has a remedy: birth control. Although derided by some religions and other opinion leaders, birth control is more important to the world’s survival than decreasing the carbon footprint, achieving peace in the Middle East, or winning back the House of Representatives.

That’s why many people were pretty excited this week when the American College of Obstetricians and Gynecologists (ACOG) came out for a simpler way for women to obtain the birth-control pill: over the counter, or OTC. If the recommendation moves forward, no longer will women need to see the doctor for a prescription. Pharmacists and health-care wonks denote this move from prescription to OTC with the old-school Communist moniker “reclassification.”

The pill has been with us for about 50 years and is one of the mainstays of population control. It is widely available and, with implementation of the Affordable Care Act, will become reimbursed completely. Planned Parenthood and other health-care facilities already make the pill and other forms of birth control readily available for anyone in need, given that the current cost for the pill is $200-400 a year.

In the U.S., about 62 million women are in their childbearing years. Of these, 43 million are “at risk” for pregnancy—the other 19 million are abstinent or sterile or already pregnant. Of those at risk, 10 million, or 28 percent, use the pill, making it by far the most popular easily reversed method of birth control for women. Tubal ligation is used by about the same number of women but is much less easy to undo. And condoms come in at 16 percent, reminding us once again of the uselessness of men.

So this is good news, right? Studies have shown that sales go way up after reclassification, and this allows the manufacturers to drop the price—a little or a lot. Cheaper and easier is always a winner. Plus, pharmacies, always wanting to move the merchandise, would be happy since they’d have a hot product and wouldn’t need to waste time and resources by having a pharmacist work the cash register or staple closed those hygienic-appearing small white paper bags. The insurance companies would be tickled, too, since they’d no longer be forking over the money for 80 percent of that prescription. And health-care bean counters would be ecstatic—according to one calculation, every dollar spent on an OTC medication saves the healthcare system 7 or 8 bucks, since it means a patient isn’t paying to see a doctor.

The other members of the dance, reps from Pharma and Insurance and government, are acting like doctors’ feelings will be hurt and their bottom lines diminished because of less patient traffic for these sorts of visits, I strongly doubt it. Nothing is less exciting or rewarding in the course of a working day than refilling a prescription. We physicians have never been good at dealing with non-sick people.

So it’s a win-win-win-win—first time ever, right?

Of course not. One person is missing in this: you, the lowly patient, aka, consumer. Leaving aside the safety argument that perhaps the OTC pill invites less safety since doctors no longer are winnowing out people who might drop dead if they take it, here is the impact: Yes, your life is easier because you will be able to get the pill right this second, without calling my office. No, you don’t need to fill out forms and show insurance cards and wrangle over copay. But guess who is paying for the whole shabang? You. Yes, you. In techno-speak, this is how it reads: “Private and government payers support the concept because it means, in theory, fewer doctor visits and a shift of the cost of drugs to the consumer, as plans typically don’t pay for OTC medications.

Already, more than half of the medications out there are available OTC, and many pharmacists and consumer groups want to expand this to allow the pharmacist to do some direct prescribing for other medications, a system called OTC-plus. It may be the next big thing that looks good to government policy people, yet leaves the patient picking up the bill.

So in the name of consumer independence, Big Pharma and Big Drug Store and Big Insurance have found a way to finally make Uncle Sam smile. Make you pay. You want $200 worth of the pill? Go for it—just pay up first. Looked at this way, reclassification would seem to threaten to push pill use down, not up, since women, many of them young 99 percent-ers, may opt to simply save a few bucks and hope for the best. More likely though, and hopefully quickly, Planned Parenthood and other organizations will pick up the slack, since they already are positioned to provide birth control for those can’t afford it.

The seemingly heroic stance of ACOG and the rah-rah for consumers need to be set into proper context. This and all reclassifications are a mixed blessing, a fact that offers us a sobering reminder of just how complex the business of paying for health care truly is. Grandma was right when she said that good health was priceless, but we still have to figure out a way to pay for it one way or another.

When things are this confusing, it always best to spend first on the biggest item—in this case, population control. Because unless the world’s insatiable urge to procreate starts to stop soon, none of the others debates will be worth the squabble.